Gerontology and Nutrition Format Review and Use Journal


Gerontology and Nutrition Format Review and Use Journal

Gerontology and Nutrition Format Review and Use Journal

a nursing study that has IMRAD (Introduction, Method, Results, Analyze, Discussion) sections in the nursing study.

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answer as many of these questions possible in relation to the article.

Appraising Nursing Studies


What is the problem identified?
What is the purpose of the study?
Review of the Literature

Is the Review of literature (ROL) relevant to the problem?
Does the review provide for critical appraisal of the major references?
Does the review conclude with a summary of the literature with implications for the study?

What is the research method?
Who is the population of the sample for the study?
Are the details of data collection clear?
What are the instrument(s) or screening tools used to collect the data?

What are the method(s) of data analysis?
Are there any tables, charts, and graphs provided?

What are the results based on the data presented?
What is the conclusions of the study?
Are the results interpreted in the context of the problem/purpose?
Are there limitations of the findings?


Geriatric Nursing 40 (2019) 640 644 Contents lists available at ScienceDirect Geriatric Nursing journal homepage: Acute Care of the Elderly Column Elizabeth Capezuti PhD, RN, FAAN Sarah Hope Kagan PhD, RN, FAAN Mary Beth Happ PhD, RN, FAAN Lorraine C. Mion PhD, RN, FAAN Elder abuse Lorraine C. Mion, PhD, RN, FAANa,*, Mary Alice Momeyer, DNP, APRN-CNPa,b a b College of Nursing, The Ohio State University, Columbus, OH 43210, United States The Ohio State University, Columbus, OH 43210, United States Introduction Elder abuse or mistreatment includes physical, emotional, sexual abuse as well as financial exploitation, neglect and abandonment.1,2 According to the National Center on Elder Abuse (NCEA), it is “an intentional act or failure to act by a caregiver or another person in a trust relationship involving an expectation of trust”.1 The abuser can be family, friends, as well as staff at nursing homes, assisted living facilities and home health care agencies. Elder abuse is a worldwide public health problem.3 In the United States, 1 in 10 older adults experience some form of elder abuse with estimates as high as 5 million older adults abused annually.1 3 Elder abuse is associated with greater risk of death, even after adjusting for a number of potential confounders. Importantly, we know that elder abuse predicts higher rates of hospitalization, readmission to hospitals, emergency department visits, nursing home placement and hospice.4,5 Thus, acute care nurses are in a pivotal role to assess, identify and report suspected cases of elder abuse or mistreatment. Barriers to identifying elder abuse or mistreatment Despite the number and consequences of elder abuse, only 4% to 7% of the cases are reported.3,4Gerontology and Nutrition Format Review and Use Journal

Identifying elder abuse and mistreatment is complex and there are a number of barriers involving the older adult, the health care provider and the health care organization. Older adults are often reluctant to report abuse due to fear of retaliation and further abuse, rejection by their caregiver(s), possible abandonment or fear of institutionalization.6,7 Additionally, older *Corresponding author. E-mail address: (L.C. Mion). 0197-4572/$ see front matter © 2019 Elsevier Inc. All rights reserved. adults may be reluctant to report their offenders, who are often caregivers, due to a sense of security of knowing their situation. For these older adults, abusive care is regarded as better than no care. Some may have shame or self-blame for what is happening to them. Older adults may not know that help is available or how to access it, further contributing to feelings of hopelessness and belief that their situation is unchangeable.10 Many older adults “normalize” their abusive situation as a part of their family dynamics and adopt general acceptance. Another barrier to reporting abuse is lack of capacity; older adults’ abilities to report may be limited due to cognitive impairment, such as dementia. Health care providers, including nurses in acute care settings, will often encounter older adults who are victims of abuse or neglect.1,3,8 Indeed, an emergency department visit or admission to the hospital may be the only time the older adult is away from his home. Nurses may not suspect presence of elder abuse because of lack of knowledge and training in detecting elder abuse and mistreatment, neutral attitudes regarding elder abuse, or fear of potential litigation.6,9,10 Further, nurses may feel uncomfortable having these discussions with older adult patients. Patient interactions are brief and time does not allow for or facilitate discussions of such personal nature. Perpetrators can be menacing or threatening, either with physical harm or litigation.11 Many nurses and other health care providers are uncertain of their role in screening and assessing for elder abuse and many view it as a social service issue. In addition, nurses and health care providers may be reluctant to pursue assessment or screening because of they lack knowledge of resources or processes to aid the older adult. Acute care hospitals are an access point for case finding.12 Hospitals provide a safe, structured environment which may be an escape for the older adult from an abusive home environment. There are opportunities to screen for and diagnose abuse in older adults seen in L.C. Mion, M.A. Momeyer / Geriatric Nursing 40 (2019) 640 644 emergency departments as well as those treated on inpatient units. However, challenges exist. Gerontology and Nutrition Format Review and Use Journal

On a systems level, many organizations lack standardized protocols and tools for detailed or focused assessment.6,8,13 Assessment of elder abuse is commonly folded into family or domestic violence in one or 2 questions, such as “do you feel safe in your environment?” Abused older adults may not interpret “safety” as an indicator of abuse. Without further direct questioning, opportunities to identify specific red flags or symptoms are lost. Risk factors for elder abuse or mistreatment As older adults access health care in the acute care setting, clinicians including nurses have a professional and legal obligation to assist with case finding, utilizing a comprehensive approach. Assessment includes the identification of risk factors or red flags that indicate a potential or likelihood of elder abuse or mistreatment, recognition of signs or symptoms, and the use of validated screening tools. Many elder abuse risk factors have been identified and are helpful in the assessment of older adults.7,8,14 With each additional risk factor, the likelihood of elder abuse or mistreatment increases greatly. In a systematic review of risk factors in community dwelling elders, Johannesen and LoGiudice identified thirteen risk factors that were common in a majority of the high quality studies included in the review.15 Risk factors encompass the older adult, the perpetrator, the quality of the relationship between the older adult and perpetrator, and the environment (Fig. 1). It is important to note that age, gender, race or ethnicity are not risk factors — elder abuse and mistreatment cuts across all segments of society. What is known is that older adults with cognitive impairment (e.g., dementia), behavioral problems (e.g., agitation, sleep disturbances) or psychiatric illnesses or problems (e.g., depression, anxiety) are all strong risk factors. Functional dependence on others for eating, bathing, dressing, and mobility as well as poor physical health or frailty have been shown to be strong risk factors. Last, financial dependence on others can be a red flag. 641 Among the perpetrators, common risk factors include expression of caregiver burden or stress and mental illness. Some have reported that substance abuse and financial dependency on the older adult are also potential risk factors.7,14 Gerontology and Nutrition Format Review and Use Journal

The relationship between the older adult and the perpetrator is an important risk factor to consider.6,7,15 Family disharmony as well as poor or conflictual relationships are common. Additional red flag caregiver behaviors that raise suspicion of abuse include substance abuse, emotional outbursts, reluctance to leave the older adult alone with the health care provider, or interruption or speaking for the older adult without allowing the older adult to speak for himself. The living environment may also raise suspicion for presence of elder abuse or mistreatment taken in combination with other risk factors. Those with low social support, i.e., few family members or friends, as well as those living with others are potential factors. Screening tools and hospital responsibilities A number of screening tools exist as a first step in determining the presence of elder abuse or mistreatment.8,16 No single screening tool is recommended as the gold standard.17,18 Nevertheless, the usefulness of a screening tool is that it provides the nurse with a standardized approach to assessing for potential abuse or mistreatment. Three tools highlighted in the 2013 Elder Maltreatment Symposium convened by the Centers for Medicare and Medicaid Services were recommended for use in practice by trained professionals.17 (See Table 1). There are many other screening tools studied for use in specific health care settings such as primary care, dental clinics, home health settings and long-term care facilities. At this time, there are no specific screening tools designated for use in acute care hospitals. Some have questioned the usefulness of routine screening of all older adults based on lack of resources and potential downside effects of falsely accusing caregivers of abuse or neglect.11 The United States Preventative Task Force (USPTF) found that current evidence is insufficient to assess the balance of harms and benefits of screening all older adults for abuse.18 In addition, the USPSTF found inadequate evidence that screening or early detection of elder abuse or abuse of vulnerable adults reduces exposure to abuse, physical or mental harms, or mortality in older or vulnerable adults. Nevertheless, screening for abuse and mistreatment is considered by many to be a quality of care indicator and part of the Joint Commission standards for hospitals (PC.01.02.09).8,13,19 As part of the Joint Commission standards, hospitals must educate staff to recognize signs of possible abuse and their role in follow-up in reporting abuse and assist with referrals of possible victims of abuse. Hospitals are to have criteria to identify patients who may be victims of abuse, use these criteria to identify potential victims, and internally reports cases of possible abuse to appropriate department(s), such as Social Service or Security departments. State laws vary in their reporting requirements; thus, hospitals designate the process within their organization for reporting the suspected abuse or mistreatment to outside agencies. Gerontology and Nutrition Format Review and Use Journal

The role of the nurse- assessment and crucial conversations Physical assessment Fig. 1. Risk Factors for Elder Abuse or Mistreatment. Nurses are in a pivotal role to identify the signs and symptoms of elder abuse or mistreatment, but identification of physical signs and symptoms of abuse can be complicated. Age related changes or diseases can mimic or mask signs of abuse. For example, older adults bruise easily and it is not unusual to see bruising along forearms or shins because of bumping into objects. Many times, the older adult 642 L.C. Mion, M.A. Momeyer / Geriatric Nursing 40 (2019) 640 644 Table. 1 Elder Abuse and Mistreatment Screening Tools. Screening Tool # Items Adminstration Setting Elder Abuse Suspicion Index (EASI) 6 Validated in family practices and ambulatory care settings Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) Vulnerability to Abuse Screening Scale (VASS) 6 Completed by health care professional to assess risk, neglect, verbal, psychological, emotional, financial, physical and sexual abuse over a 12 month period; 2 min to complete Self report or interview by a professional Self report of dependency, dejection, coercion and vulnerability N/A 12 may not remember the source of the bruise. There are, however, certain patterns of injury and fracture that are more indicative of abuse than accidental trauma. Bruising on the head, neck, abdomen, inner aspects of the arms and thighs, posterior legs and spiral long bone fractures suggest abuse.7,20,21 Healing of bruises and lacerations in various stages may be suggestive of abuse. Observe for signs of neglect. Gerontology and Nutrition Format Review and Use Journal

These include unkempt or dirty appearance, pressure ulcers, malnutrition or dehydration. Assess the appropriateness of dress for the season. Assess for adherence to medication regimen. Observe the older adult’s behavior with the caregiver. Does the older adult become passive in responding to questions? Does the older adult appear anxious or tense in the presence of the caregiver, but relaxed when the caregiver is not present? What are the caregiver’s behaviors? Does the caregiver interrupt or contradict the older adult’s statements? Suitable in emergency or outpatient settings Table 2 Direct questions to identify potential elder abuse or mistreatment. Psychological/Emo- tional Abuse Physical Abuse Financial Abuse Neglect Sexual Abuse “Are you afraid of anyone at home?” “Have you been slapped, hit, kicked or pushed around?” “Have you been locked in a room or tied up?” “Does anyone hurt or abuse you?” “Do you feel put down, made fun or ridiculed by your caregiver?” “Have you been threatened to be put in a nursing home?” “Have you been shut off from seeing or talking with people outside the home?” “Has anyone ever asked you to sign documents that you didn’t want to sign?” “Has anyone taken your money without permission?” “Has anyone taken your valuables?” “Are you made to stay in your room or left alone a lot?” “Has anyone ever failed to help you when you needed help?” “Do you have enough to eat and drink each day?” “Has anyone touched you without your permission?” “Has anyone forced you to have sexual relations?” Crucial conversations Many nurses do not see themselves having a participative role in elder abuse case finding and/or assessment.9,10 Typically, social workers have been delegated the lead in gathering information and formally reporting if indicated. However, nurses have the most direct patient contact time which can foster a trusting relationship and confidence. Some patients will talk with their nurse about their abusive situation, concerns and vulnerabilities if they feel safe and supported. There are verbal and nonverbal strategies that foster open communication. The nurse should consider the following: 1. Demonstrate sensitivity to the individual’s cultural, Gerontology and Nutrition Format Review and Use Journal

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